NYSDA Publications

AHRQ Issues Patient Safety Morbidity and Mortality Report

The Agency for Healthcare Research and Quality (AHRQ) has issued its latest Patient Safety Morbidity and Mortality Report.  You can read the latest AHRQ Patient Safety Morbidity and Mortality Report below.

WebM&M Cases & Commentaries

The Unhappy Patient Leaves Against Medical Advice

This WebM&M case discusses a 61-year-old inpatient that was on bedrest following postoperative complications.  During the night shift, the hospital unit was short-staffed, and her external catheter system fell off.  The patient rang her call button repeatedly to request nursing assistance and eventually hopped down the hallway on one leg to find assistance but was unsuccessful and went back to her room.  By the time the nurse came to the bedside to change the patient’s urine-soaked bed pads and sheets, the patient was angry and agitated.  The nurse responded defensively and began to talk to the patient in a condescending tone and another nurse on duty complained to the family member that the patient was “behaving badly.”  Ultimately, the patient decided to “leave against medical advice,” (AMA) despite having bedrest orders, citing she was extremely upset about how she was treated and spoken to.  She was escorted downstairs to leave the hospital, accompanied by her family member, and was given her doctor’s name and contact information.  No nurse or physician on duty was able to provide discharge education, instructions, or medications related to her DVT or urinary incontinence.  The charge nurse was unaware of these events until the on-call physician contacted the unit for more information about what happened.  The commentary discusses the risks of patients leaving AMA, summarizes effective communication strategies to mitigate the risk of patients leaving AMA and highlights strategies for prevention and de-escalation.

Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong

In this WebM&M spotlight case with CE/MOC, a 49-year-old woman presented to an Emergency Department (ED) with abdominal pain nine hours after discharge following outpatient laparoscopic left oophorectomy.  The left oophorectomy procedure involved an umbilical port placed using an Optiport visual trocar, a suprapubic port, and two additional ports laterally.  The operative note mentioned no visible injury upon entry into the abdominal cavity, but there were extensive adhesions in the pelvis.  Nine days after discharge, the patient presented to another hospital due to increasing pain, nausea, and fever.  The patient underwent a laparotomy and the surgical team found fecal contamination upon entry into the peritoneal cavity; the surgeons concluded that the most plausible explanation was a trocar injury.  The commentary discusses the risk of vascular and bowel injury during peritoneal access for laparoscopy and the importance of patient history and abdominal anatomy when considering approaches to abdominal entry.

False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy

In this WebM&M spotlight case with CE/MOC, a 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications.  The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR).  After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR.  He left the PACU without communicating with the bedside nurse, who was caring for other patients.  The patient informed the nurse that the attending physician had no concerns.  While preparing the patient for discharge, the nurse paged the fellow requesting discharge orders.  The fellow assumed that the attending physician had reviewed the CXR and submitted the discharge orders as requested.  Thirty minutes after the patient was discharged the radiologist called the care team to alert them to the finding of pneumothorax on the post-procedure CXR.  The commentary summarizes complications associated with bronchoscopy and strategies to improve perioperative safety.

Curated Libraries

Curated Libraries are groupings of PSNet content, curated by AHRQ and other patient safety experts.  Watch our introductory video to learn more about this new feature and how it can be of benefit to you.

Diagnostic Safety

Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.